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2 prof james bently differentiating high and low grade
1) Differentiating between high grade (CIN 2/3) and low grade (CIN 1) cervical lesions is important for treatment decisions. 2) Colposcopic features that suggest high grade lesions include coarse mosaicism, irregular blood vessels, thick opaque white epithelium, well-demarcated ridges, and papillary configurations with sharp borders. 3) Low grade lesions typically have features like a transient whitening with acetic acid, fine punctation, ill-defined margins, and peripheral or small sizes.
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2 prof james bently differentiating high and low grade
- 1. COLPOSCOPY OF CIN; DIFFERENTIATINGHIGH GRADE FROM LOW GRADE LESIONS James Bentley , Professor Department of Obstetrics and Gynecology, Dalhousie University, Halifax NS, Canada
- 2. Normal CIN 1 CIN 2 CIN3 Cancer
- 3. Progression/Regression of CIN RegressPersist Progress to CIS Progress to invasion Months to CIS from baseline CIN 1 57% 32% 11% 1% 58 CIN 2 43% 35% 22% 5% 38 CIN 3 32% <56% - >12% 12 OsterAG. Int J Gynecol Pathol 1993;12:86 Richart RM, Barron BA. A follow-up studyof patientswith cervical dysplasia.Am J Obstet 1969;105:386–393 Resolution of CIN 1 in adolescent is 90% CIN 3/ CIS progression to cancer in 31% of cases treated by Bx; McCredie et al Lancet Oncology 2008 9(5) 425-34
- 4. ASCUS LSIL Images downloaded fromhttp://nih.techriver.net/bethesdaTable.php
- 5. Results: hc2 +ve Papsmear history Number of cases HybridCapture 2 +ve 1 95%Confidence intervals ASCUS/ASCUS 87 58 (67%) 56% to 76% ASCUS/LSIL 33 23 (74%) 52% to 82% LSIL/ASCUS 19 18 (95%) 73% to 100% LSIL/LSIL 21 15 (71%) 49% to 86% All cases 160 114 (72%) 64% to 78% 1 note 10 specimens had insufficient sample •No significant difference between groups for hc2 Triage using repeat ASCUS or LSIL pap smears; is there any difference between categories? Bentley et al IFCPC 2008
- 6. Results: CIN2 +on Bx Pap smear history Number of cases CIN 2 or greater 95%CI ASCUS/ASCUS 87 23 (26%) 18% to 37% ASCUS/LSIL 33 7 (21%) 10% to 38% LSIL/ASCUS 19 2 (10.5%) 1.7% to 32% LSIL/LSIL 21 3 (14%) 4% to 35% All cases 160 35 (22%) 16% to 29% •No significant difference between groups for histology Triage using repeat ASCUS or LSIL pap smears; is there any difference between categories? Bentley et al IFCPC 2008
- 7. CIN2 and 3after low grade cytology ALTS trial: Progression to CIN2 or 3 in 13% of women referred for the evaluation of LSIL or ASCUS HPV +ve smear NS Data: 2ASCUS, 2 LSIL, or combination HR HPV +ve 72 % CIN2 or > 22%
- 8. ASC-H Images downloaded fromhttp://nih.techriver.net/bethesdaTable.php
- 9. CIN2 or >after ASC-H Significant pathology seen in the majority of cases Barreth et al.: CIN2 or > in 70% of cases 2.9% invasive disease 1.7%AIS
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- 11. CIN2 or >after HSIL WrightASCCP: CIN2 or > 53%-66% with Biopsy 90% if policy of immediate colposcopy
- 12. AGC cytology Pathology finding1 CIN1 7% CIN 2 or 3 36% Adenocarcinoma in situ 20% Cervical Cancer 9% Endometrial Pathology 29% 1Daniel A Int.J.Gynaecol.Obstet 2005; 91(3)238-242 2 Wright T Emerging Issues on HPV infections 2006 p 140-146 Cytology2 Any high-grade lesion High grade glandular AGC-NOS 9-14% 0-15% AGC-N 27-96% 10-93%
- 13. ASC-H Colposcopy NoCIN Manage as perSCC guidelines CIN1 or > Colposcopy, cytology, at 6 months x 2 (HPV testing at 6 or 12 months ideally) Return to screening protocol CIN 1 or > No CIN HPV +ve follow in colposcopy clinic
- 14. HSIL Colposcopy (Bx, +/- ECC) NoCIN2, 3 Manage as per SCC guidelines CIN 2 or greater Satisfactory Colposcopy Unsatisfactory Colposcopy Observe with Colposcopy and cytology Q 6/12 x2* Return to screening protocol Diagnostic Excision procedure * Consider HPV testing Cytology/histolo gy review disagreeagree
- 15. Colposcopic Approach Examinewhole lower genital tract Use acetic acid liberally Beware the small lesion Take >1 biopsy Liberal use of ECC Always do ECC with unsatisfactory colposcopy
- 16. High grade features:Snow white epithelium
- 17. Low grade colposcopic features:colour The acetowhite reaction is slower in onset and more transient than high grade lesions Semi-transparent Snow-white colour Gray-white colour higher grade
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- 19. Low grade Colposcopicfeatures: size / position Peripheral lesions Often smaller
- 20. Low grade Colposcopicfeatures: size / position
- 21. Low grade Colposcopicfeatures: margins Feathered Geographic Flat with indistinct margins Satellite lesions
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- 23. Low grade Colposcopicfeatures: margins
- 24. Low grade Colposcopicfeatures: margins
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- 29. High grade features:Coarse Mosaicism
- 30. Low grade Colposcopicfeatures: vessels Ill defined areas of fine punctation or mosaicism
- 31.
- 32. High grade features:Irregular vessels vascularity Hair pin vessels from cancer Punctation from CIN2
- 33. High grade features:Thick keratosis
- 34. High grade features:inner border sign
- 35. High grade features:ridge sign
- 36. High grade features:papillary lesion; sharp border
- 37.
- 38. CIN 3 inpregnancy
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- 40. CIN 2 Photocourtesy of Dr LGeldenhuys Histology of CIN 2
- 41. CIN 3 Photocourtesy of Dr LGeldenhuys Histology of CIN 3
- 42. CIN 1 onBiopsy or ECC SatisfactoryColposcopy Observe with Colposcopy and cytology Q 6/12 x2 Return to screening protocol Unsatisfactory Colposcopy Observe with Colposcopy and cytology at 24 months2 Treatment1 1 consider ablative therapy for persistent CIN1 2 if cytology persists continue FU in colposcopy Colposcopy and cytology -ve CIN persists or progresses Observe with Colposcopy and cytology 12 months persisten t
- 43. CIN 2,3 on Biopsy Returnto screening protocol Diagnostic Excision procedure CIN 2,3 Treatment1 SatisfactoryColposcopy Unsatisfactory Colposcopy Follow-upat 6 and 12 months with colposcopy and cytology Follow-upat 6 months with colposcopyand cytologyand HPV2 OR Treat per guidelines CINNegative 1 LEEP or excision preferred for CIN 3 2 HPV testing for high risk HPV
- 44. CIN 2,3 onBiopsy in women < 25 yrs old CIN 2 Return to screening protocol Diagnostic Excision procedure CIN 3 Observe with Colposcopy and cytology Q 6/12 x2 yrs Treatment SatisfactoryColposcopy Unsatisfactory Colposcopy CIN persists or progresses CIN Resolves
- 45. CIN 3 withAIS (on final LEEP)
- 46. HSIL pap: colposcopicview after acetic acid
- 47. 21 yr oldG0 P0 with LSIL pap, CIN 1 on Bx 20 yr old with ASC-H on pap andCIN 2 on Biopsy Adolescent
- 48. Conclusion CIN 1does not warrant therapy as most will resolve spontaneously CIN 3 and CIN 2 are recognised cervical cancer precursors They can be identified following both high grade and low grade cytology The colposcopic features should allow differentiation between CIN 1 and CIN 2/3